Refer A Patient

Please use the contact forms below to send us information on referrals. Or you may download a form if you prefer.

Referral to Ian Cross, Specialist Endodontist & Prosthodontist

Root Canal WorkRestorative Work

Your Details

(You will receive a copy by email of the infomation you submit)
Name

Email

Patient Details

Name

Gender
FemaleMale

Date of birth

Address

Postcode

Email

Telephone Numbers
Home
Work
Mobile

Referral Reason

History of present complaint

Relevant Medical History (including medications/allergies)

Any treatment carried out already (It would be helpful if a radiograph is forwarded with this form)


Other relevant information

Referring GDP Details

GDP Address

GDP Telephone

GDP Email

(Spam protection)

Referral to Mamdouh Al Chihabi, Speciality Paediatric Dentist

Your Details

(You will receive a copy by email of the infomation you submit)
Name

Email

Patient Details

Name

Gender
FemaleMale

Date of birth

Address

Postcode

Email

Telephone Numbers
Home
Work
Mobile

Referral Reason

History of present complaint

Relevant Medical History (including medications/allergies)

Any treatment carried out already (It would be helpful if a radiograph is forwarded with this form)


Other relevant information

Referring GDP Details

GDP Address

GDP Telephone

GDP Email

(Spam protection)

Referral to Mr Alan Gowans, Consultant & Specialist in Orthodontics Lead Consultant Orthodontist Cleft Lip & Palate

Your Details

(You will receive a copy by email of the infomation you submit)
Name

Email

Practice details

Referring practice

Date referred

Referring Dentist

Tel no.

Address

Postcode

Email

Patient Details

Patient's name

Email

Patient's Address
Postcode

Telephone Numbers
Home

Work

Mobile

Date of birth

Is this referral urgent?
YesNo
Reason for referral

Observations / Medical History
(It would be helpful if a radiograph is forwarded with this form)

(Spam protection)

Download Referral Forms

Ian Cross - Referral Form (PDF)

Specialist Endodontist & Prosthodontis

Mamdouh Al Chihabi - Referral Form (PDF)

Speciality Paediatric Dentist

Alan Gowans - Referral Form (PDF)

Consultant & Specialist in Orthodontics Lead Consultant Orthodontist Cleft Lip & Palate

The Bramhope Dental Clinic
2 Breary Lane East
Bramhope
Leeds LS16 9BJ

0113 2300359

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At The Bramhope Dental Clinic, the need for strict confidentiality of personal information about our patients is taken very seriously.   We have a ‘Confidentiality policy’ which is a condition of employment for all staff members which ensures that any information revealed by our patient to the dentist, nurse or reception team will not be divulged without our patient’s written consent.

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